Steven Lewis Access Consulting Ltd. Saskatoon SK (306) 343-1007 Steven.Lewis@sasktel.net

1. Seizing the Health Human Resource Future:Changing the Culture, Positioning for SuccessPresentation to the CAAHP Annual General MeetingOttawa, May 28, 2014 Steven LewisAccess Consulting Ltd.Saskatoon SK (306) 343-1007Steven.Lewis@sasktel.net

2. What This Presentation Is About • Why health care is what it is • Why health care is about to change • Implications for the workplace • Implications for the workforce • Implications for health science education • Winning conditions for tomorrow’s workforce

3. My Perspective • How we educate and deploy people should be based on needs • There is a mismatch between what people need and what the system delivers • Meeting needs successfully will require significant changes in the classroom and the workplace • It will require a coalition of educators, employers, and governments to get this done • These issues are not settled – feel free to disagree

5. Part 1 History Is Not Destiny:A Dose of Realism Tempers aCentury of Boundless Optimism

6. The Century of Achievement and Optimism • The 20th century created modern health care • Life expectancy rose 30 years • Major diseases were conquered (polio, smallpox) • Technological innovation flourished • Occupations grew in number and became highly professionalized • Scientific knowledge increased exponentially • Dramatic repair work (antibiotics, transplants, CABG, Tommy John surgery for baseball pitchers)

7. And We Thought It Would Only Get Better • Science will solve every health problem – just a matter of time and effort • More is better: • Imaging • Screening • Surgical repair • Drugs • Specialization is good; sub-specialization is better

8. Then Reality Set In • To Err Is Human in US; Baker-Norton in Canada – the system isn’t very safe • The system fails at the basics: • Hand-washing • Evidence-based preventive care (McGlynn et al) • More can be worse • PSA and mammography screening • Polypharmacy • CT scanning • Specialization is a risk factor (complexity)

9. But the Triumphalist Culture Persists • Sophisticated diagnostics • Emergency interventions • Surgery • Drugs • Big Science (genomics, proteomics)

10. What If We Started Over and Designed the System to Meet Societal Needs? • Chronic diseases consume 70% of health spending • Mental health problems are under-diagnosed and poorly addressed • Science has yet to find cures for the most prominent pathologies • Aging and frailty are the most dominant health problems • The search-and-destroy paradigm of medical miracles does not apply in these circumstances

11. What Most People Need to Thrive • Providers who listen as much as they talk • Coaching to support self-management • Relationships based on trust • Practical, on-the-ground problem solving • Emphasis on quality of life and adaptation • Engagement in their care planning and respect for their perspectives, values, choices

12. Or Put Another Way… • Patient-centred, holistic care • Better quality • Better value-for-money (VFM) • Reduced disparities between population groups • More effective prevention and chronic disease management • Integrated, effective primary care • Interdisciplinary collaborative practice • More self-reliant, health-oriented public

13. Part 2 Implications for Health Human Resources

14. Why the Workforce Looks Like It Does • Regulation gave major boost to safety in early part of 20th century • Increased complexity of health care led to increased specialization • Expansion of scientific knowledge created rationale for longer educational programs • Intrinsic societal belief in more education, higher credentials • Turf = control = power = money

15. Is the Contemporary HHR Approach Compatible With System Goals? • High degree of specialization a challenge to holistic, integrated care • Professions develop distinct theories and cultures of health and health care which risks fragmentation • Increasing entry-to-practice credentials makes workforce adjustments long and difficult • Entrenched hierarchies and power inequalities • Battles over scope of practice and gatekeeping role

16. The Revival of Generalism • The reorganization and renewal of primary health care • Interdisciplinary • Holistic • More effective division of labour • Whole-person focus with integrated approach to care • Shift from prescriptive interventionist role to coaching and shared power arrangement • Repatriation of work from specialists

17. What Makes Effective Health Care Workers? • Less autonomous practice, more teamwork • Greater emphasis on communications, coaching, behaviour modification skills • More fluid division of labour among occupational categories • Relationships and deep understanding of patients at least as important as technical skills

18. The Policy Front: Will Frustrations Lead Governments to Insist on Change? • “Credential creep” fatigue – the higher credentials aren’t creating a better system • Shift locus of health science education to colleges from universities • Expand scope of practice of technicians and aides • Mandate interprofessional training, team-based practicums • Press for inclusion of more systems thinking and quality improvement in curricula

19. Part 3 Opportunities for Allied Health Professions:Needs, Roles, Strategies

21. Lessons from US Manufacturing • Old model of US manufacturing: low-skill assembly-line mass production • Threat: cheap labour and economies of scale in developing nations • Result: major decline in US manufacturing sector • Insight: identify high-value-added, high quality end of manufacturing that cannot be outsourced • New workforce model: diploma-trained personnel working with complex, computer-based machinery

25. The Evidence Is Already In • Most scope of practice expansion has been highly successful: • Nurse anaesthesia, endoscopy, NPs • LPNs in all settings • Dental therapists • Rehab therapists as diagnosticians • Main barriers are professional self-protection and obsolete standards and regulation • The workplace and experience are great teachers that expand capabilities

26. Potential for Substitution • “Labour substitution: • Is a plausible strategy for addressing workforce shortages • Can reduce (wage) costs - under certain conditions which can be challenging to meet • Can improve efficiency - under restricted conditions which are difficult to meet” • Source: Univ. of Manchester, Centre for Workforce Intelligence, http://www.cfwi.org.uk/publications

27. Cultural Changes on the Horizon • Standardized work (care pathways, diagnostic algorithms) • Self-organizing teams with fluid division of labour • Assertive generation that exercises greater control over nature of care • Enhanced transparency and more robust public reporting about safety, quality, efficiency

28. Teamwork • Fundamental disconnect between health are hierarchy and optimal team functioning • Self-organizing teams that allocate work to maximize value of all members is ultimate goal • Interdependency and trust are prerequisites for best combination of quality and efficiency • Providers prepared to work in teams and understand team dynamics are key to developing care models • A relentless focus on safety and quality breaks down hierarchy – “stop the line” is the new mantra

29. Skill Sets for a Better Future • Ability to apply sophisticated technologies effectively • Coaching and motivation for self-management and successful adaptation • Flexibility and multi-tasking in changing environments • Data-driven quality improvement • Team-based problem-solving

30. What Kind of People Are We Looking For? • Versatility and adaptability • Emotional intelligence in workplace • Empathy and culture of service toward clients • Communication • Within teams and organizations • With people served • Creative problem-solving

31. Keep Education Short, Modular, and Experience-Based • The workforce needs educational programs that produce job-ready graduates in a timely manner • Avoid temptation to lengthen formal training – it reduces pool of interested students, adds costs, reduces agility • Enhance life-long modular learning opportunities • Remove needless barriers to shifts in career direction

32. Match Program Design to Needs • Aging and frailty • Working with families • Coaching and self-management • Recognizing mental health issues

33. Expose Students to System Concepts • Accountability • Value for Money • Indicators • Quality Improvement • Patient-Centered Care

34. Influence Regulation and Legislation • Champion evidence-based scope of practice • Question unjustified barriers to deployment of knowledge and skills • Make the process transparent and engage employers and the public in discussions • Ensure governments and employers understand changes in competency

35. Be Careful About Specialization • Narrow job descriptions and competency profiles risk obsolescence • Workplaces need skilled personnel who can evolve continuously as the environment changes • Some highly technical work demands specialization but a great deal does not • Knowing how to problem-solve where uncertainty exists is the value proposition for health care in the future

36. Create A Service Culture • The patient experience is as important as the technical aspects of care • Convenience, communication, and relationships are critical to the patient experience • Organizing work around the needs and preferences of patients is revolutionary